Acupuncture tropes on parade

I sometimes catch flak for repeating this, but there was a time when I thought there might be something to acupuncture. I don’t care, because, as a blogger, when I write a post I assume that a significant fraction of people reading it have never seen this blog before and therefore aren’t even the least bit familiar with what I’ve written before on the subject. That makes them a blank slate, as far as this blog is concerned, and obliges me to explain everything. That time was about nine or ten years ago, and my rationale was, not surprisingly, that, unlike many other alternative medicine interventions, acupuncture involves a physical manipulation that conceivably could do something physiologic. Of course, I never bought the nonsense about how tiny little needles would somehow redirect the flow of qi (life energy) to healing effect. I did, however, figure that maybe there was something to the whole hand wavy bit about releasing endorphins or the adenosine. I wa s wrong. The more I delved into the primary scientific literature about acupuncture, the more I realized that there really is no “there” there, so to speak. Acupuncture is, as David Colqhoun and Steve Novella have put it, a theatrical placebo.

Unfortunately, by and large, in the popular literature the portrayal of acupuncture is largely without skepticism, as though it actually works. Over the weekend, i saw a particularly egregiously credulous treatment of acupuncture online for Washingtonian Magazine by Elissa Miolene entitled Acupuncture: Demystifying an Ancient Practice. I knew it was going to be bad, bad, bad, as soon as I read the subtitle, Why a 2,000-year-old medical practice is being used by Washingtonians today.
After I came across this article, I decided to take a look at it for a couple of reasons. First, it’s chock full of common misconceptions about acupuncture. Second, it’s the very epitome of false balance. No. Strike that. There’s no balance, false or otherwise. The entire article is basically a promotional article for acupuncture, specifically acupuncture services in the Washington, DC area, that is so devoid of skepticism, so devoid of the knowledge of the real history of acupuncture. Miolene starts out with—of course!—an anecdote, hers, in which she undergoes acupuncture and is surprised that it doesn’t hurt as much as she expected. Then, she completely buys into the revisionist history of acupuncture promulgated by acupuncturists and other advocates of acupuncture that presents it as being some sort of ancient discipline that was “discovered” by the West in the 1970s. Really, Miolene should be ashamed and embarrassed at how wrong she gets it:

Acupuncture is an ancient Chinese technique far older than the city of Washington. Some research suggests acupuncture was a common practice as early as 2797 BC. As time went on, acupuncture progressed and was perfected, and the opening of trade routes lead to its spread.

America’s first taste of acupuncture began in the early 1970s. Today, it is officially recognized as both a treatment and a practice, covered on numerous insurance plans including Medicare.

But many still see acupuncture as an out-there practice that has tentative results. However, a 2007 NIH study said that of 5,981 patients suffering from long-term pain, the average success rate after acupuncture treatment was near 80 percent.

This is the study. I can’t help but note that it’s in a journal called Acupuncture in Medicine, which is—shall we say?—not exactly the best journal out there (to put it mildly). I also can’t help but note that this article has nothing to do with long term pain; rather, it’s a systematic review of the literature regarding acupuncture for anxiety and anxiety disorders. You can read it for yourself, but basically it shows nothing, concluding (as is the case with most systematic reviews of acupuncture as an intervention for, well, anything) that “there is currently insufficient evidence from research on acupuncture in the treatment of specific anxiety disorders for firm conclusions to be drawn.”

Same as it ever was. It is, however, rather sloppy not to use the right reference.

I couldn’t resist taking a look at the acupuncture practice where Miolene got her acupuncture treatment and, most likely, much of the information she used in this article. The practice is Transformational Acupuncture, and it’s located in one of my favorite parts of Washington, DC, a part of the city I like to visit whenever I happen to be in DC, namely DuPont Circle. There, a team consisting of acupuncturists and traditional Chinese medicine herbalists peddle their woo to affluent (and almost certainly mostly white, given the location) DC denizens under the leadership of the founder Jeremy Riesenfeld. As is the case with so many who have embraced quackery, Riesenfeld provides a story of “personal healing,” in which he describes his health thusly:

My health was pretty much in shambles – I had bad digestive problems, fairly bad depression, chronic fatigue, and anemia. Luckily, I had signed up for a work-study program at Heartwood Institute, a training center for the holistic healing arts in Northern California, and began my stay there immediately after school.It was there that I was introduced to a wide variety of holistic healing practices – what I now call the 8 Branches of Chinese Medicine. As I received treatment, and practiced meditation, yoga and tai chi, ate a new diet, took herbal medicine, got acupuncture and bodywork, and began addressing my difficult thoughts and emotions, I began to heal.

Actually, I wasn’t entirely correct. Apparently Miolene also got her information from another acupuncture practice, Urban Tao Acupuncture and Herbology, which offers both acupuncture and traditional Chinese medicine.

Now here’s the closest Miolene gets to anything resembling skepticism:

Some critics say a placebo effect is all acupuncture provides. Reisenfeld, not surprisingly, doesn’t see it that way. “If someone’s back pain goes away immediately, and that’s something physical therapy, medication, and yoga didn’t help, why would placebo all of a sudden be able to override past experience because you’re getting acupuncture?” he said.

One can argue that if anything, alternative forms of medicine like acupuncture suffer from the placebo effect instead of benefitting from it. “It’s ingrained that you grow up trusting your doctor more and alternative medicine less.” Boudhili said.

What the heck does that last part even mean? “Suffer” from the placebo effect? That’s all that’s there in acupuncture, placebo effects. It’s all that the therapy has. As for the first part, Reisenfeld is making the same mistake that believers in alternative medicine always make, namely an argument from incredulity. Just because he can’t believe that placebo effects can give the illusion of improvement when other treatments have failed just means that he doesn’t know very much about placebo effects. Sometimes, just trying something new is enough to invoke placebo effects.

I also like how this part is phrased, “Some critics say…” Who are these critics? It’s quite clear from the article that Miolene didn’t bother to interview any critics, as in physicians advocating science-based medicine who can explain how acupuncture is in reality based on prescientific vitalism and how all the science acupuncture apologists use to try to “explain” how it allegedly works comes down to what Harriet Hall likes to refer to as Tooth Fairy science. For those of you not familiar with the term, that’s science studying a phenomenon that hasn’t been shown to actually exist as if it had been proven to exist. As Harriet puts it, we can study the amount of money left by the Tooth Fairy in different settings, but since we haven’t determined that there is really a Tooth Fairy, any conclusions we reach will be falsely attributed to an imaginary being rather than to the real cause (parental behavior). The analogy to acupuncture is obvious.

Finally, one can’t help but note that Miolene falls for the appeal to antiquity, the claim that acupuncture is thousands of years old. While something sort of resembling acupuncture is thousands of years old, what that something was was most likely a form of bloodletting not unlike the bloodletting practiced in the West. Acupuncture in its current form is largely a 20th century invention that was popularized not by Chinese healers but by Chairman Mao, who used it as a substitute for “Western” medicine when he couldn’t provide enough physicians to care for his people. Embarrassingly, in a graphic, Miolene also buys into the “acupuncture anesthesia” story of James Reston in 1971, which was not really acupuncture anesthesia and likely didn’t significantly help Reston. The same graphic touts how the NIH “legitimized” acupuncture in 1997. I’m guessing that it’s referring to the 1997 NIH Consensus Development Conference Statement that is highly flawed because most of the research referenced occurred before the time when effective sham placebo procedures had been developed to use in randomized clinical trials as placebo.

Perhaps the most highly misleading part of this graphic is the part that proclaims “President Obama recognizes acupuncture as a profession” in 2014. Personally, I must have missed that one, because I never heard about it in 2014, and, given what this blog is about, I highly doubt I could have missed stories about something that, had it happened, would have been monumental in the world of “integrative medicine.” So I did some Googling. Apparently what Miolene is referring to is a Change.org petition asking the government to recognize acupuncturists as health care providers under Medicare. The response by the Obama administration was hardly what I would characterize as “recognizing acupuncture as a profession.” I mean, seriously, did Miolene even read the danged thing? Basically, it said that acupuncturists are not recognized as health professionals under Medicare because the statute doesn’t include them and that to recognize them as such would require passing a change in the relevant statute by Congress, even going so far as to say:

As prescribed by law, CMS develops NCDs [National Coverage Determination]. These national policies, which are made through an evidenced based process with opportunity for public participation, serve as generally applicable rules to ensure that similar claims for items and services are covered in the same manner. NCDs may grant, limit, or exclude Medicare coverage for particular items and services, and there are three NCDs on acupuncture. After careful study of the available evidence, it was concluded that acupuncture is not reasonable and necessary under section 1862(a)(1) of the Social Security Act. Therefore national noncoverage for acupuncture continues.

Some might wonder why I did a one of my typical posts about an article in a publication like Washingtonian about how great acupuncture is and why it’s so popular in our nation’s capital, as evidenced by the proliferation of acupuncture practices all over DuPont Circle and beyond. The reason is simple. Rarely have I seen such a nice (if you can call it that) distillation of very common tropes and misinformation about acupuncture used by acupuncturists to promote their quackery that are frequently repeated in news stories and almost just as frequently go completely unchallenged. That’s all it takes. That, and nothing else catching my attention last night.

32 Comments

Why a 2,000-year-old medical practice is being used by Washingtonians today.

Because credulous people buy into sCAM up to the point of believing accupuncture is 2.000 year old? Do I win anything?

What the heck does that last part even mean? “Suffer” from the placebo effect?

Maybe he believes that acupuncture is a beneficial intervention, which real effects are then nullified by nocebo effect? Kinda turning the whole thing upside down, but that is how I understand that part of article.

I always wonder about Appeal to Antiquity, why do people so eagerly equate that something is old with it being good. The real age of modern acupuncture aside, some antique things were pretty horrific. Say, why not reinstate slavery on the basis it worked perfectly since ancient times? It was not 200 years since it was abolished, which was obviously mistake seeing how it has such a long, storied tradition. And how about bloodletting? I don’t know why it was ever dropped as an universal therapy, I mean it was A OK for hundreds of years!

What the heck does that last part even mean? “Suffer” from the placebo effect?

It looks like this person is trying to say that, because of the bad press acupuncture and other alt-med treatments receive, patients starting position/expectation is one of mistrust and the baseline will be a negative placebo effect.

In other words, if it’s not working, it’s because of negative thoughts from the patient or his/her entourage.
Damn skeptics, you ruin everything.

Antique acupuncture may have been a form of bloodletting (between the bigger needles and the meridians following the surface blood vessels), so your question could be more apropos than you think.

Remembering some past articles about cupping, slapping and other bloody “detox” treatments, I would not be surprised if acupuncturists are more likely to support these bloodletting variants.
Because, after all, it’s that bloodletting was about: “detoxifying” the blood.

” …by Chairman Mao who used it as a substitute for “Western” medicine when he couldn’t provide enough physicians to care for his people.”

Many threads ago when the question was brought up why woo is taking off in medicine, I had this exact thought about where our medical care is headed. True believers now, but to include Orwellian and forced believers later because this is cheaper than, you know, delivering real medicine. I didn’t realize there was a historical precedent for it. If you weren’t writing this blog out of the love of your heart, and I had money, I would pay you to write it because…

This needs to stop. If people’s emotional needs are not being met then set up community centers, visit the lonely, heck visit your neighbors; anything but sell people lies in medicine in order to fix their emotional health Some here are comfortable with lies but there is a reason truth is valued. Lies bite us all in the a$$ eventually.

The Smith of Lie – My favorite is trepanation. I feel there is far too little of it today. Seriously though, if it brought back common sense into the world, I would be its advocate.

My reading of ‘suffer from the placebo effect” is that she’s arguing that because placebo acupuncture works just as well as real accupunture, it’s not possible to demonstrate real acupuncture works by some mechanism other than palebo effect: when real acupuncture does work its benefits are wrongly assigned to placebo effects rather than its ability to actually change qui flow through invisible meridians.

Or more concisely “Those damn placebo controls are preventing manyone from proving what I already know to be true!”

I imagine she means that having learned to trust SBM works against trusting in acupuncture and thus experiencing its benefits- placebo and real.

And -btw- acupuncture is like Oakland?

Also, in physio class, the prof speculated that if acupuncture INDEED worked, it might involve endorphins or the irritation it produced interfering with pain signals but let’s not believe it until we can show it happening. 30 years later, still haven’t seen any evidence of that.

Mark Crislip* notes that acupuncturist don’t seem to believe in germ theory, as you never see a picture that shows an acupuncturist wearing gloves. I note that the accompaning photo shows one gloved and one ungloved hand, so I guess that’s progress.

No need for Orac to be apologetic about having “thought there might be something to acupuncture”, or for writing about Mioloone, err, Mioline’s puff piece. We get a concise explanation of needling’s plausibility — “unlike many other alternative medicine interventions, acupuncture involves a physical manipulation that conceivably could do something physiologic”. And Mioline’s puff piece claims exactly that, with no reference to meridians, vitalism, or balancing qi: “…triggers the brain to manufacture pain killers for a given area” she quotes her needler. She also doesn’t seem to know what a placebo effect is:

if a person does suffer from anxiety or stress, being forced to be still for an hour-long session can be healing in and of itself… In other words, people who suffer from anxiety will essentially train their brain to relax more easily.

Which may be true, but has nothing to do with sticking needles into meridians.

But I have the feeling this is how most people who visit acupuncturists see things. They don’t buy into the details of the theory, they just think “it works”. It’s not Appeal to Antiquity, but to folk wisdom and tradition. It’s considered “good” because it’s thought to have been around a long time without going away, not like bloodletting at all. The practitioner is considered to have discovered that it ‘works’, not WHY it works — just as a shaman of a tribe in the Amazon headwaters not yet know to Western Civ may know an amazing provably valid herbal cure, also not yet known to ‘science’, but attribute it’s effects to some bizarre mystical cosmology.

I have an artist friend who’s fairly woo-ey in a very NoCal way. He certainly thinks acupuncture is a good thing in general. He doesn’t use it, at least not regularly, though he thinks it’s a good when psych service clinics offer it. That’s where his health issues lie, and he’s convinced the holistic thing works for that — that there’s a body-mind connection, and thus yoga, ‘healthy’ food smoothies, “bodywork” and other neck-down stuff help him from the neck-up. But this is a very general principle, and he’s not really into specifics. Like I said, he’s an artist, and he works at a gallery where ‘developmentally disabled’ folks make and sell artwork (which seems pretty cool, actually). So he doesn’t get into the weeds of explanatory details, and views these things through a poetic sensibility. So if body-helps-mind, why wouldn’t the inverse be true?

My point here being that Orac and the bloggers at SBM often attack acupuncture on the basis of what acupuncturists claim it will do, and how it works — but that’s not necessarily what it’s enthusiasts believe exactly, and debunking that isn’t going to raise more than a shrug. And no number of large population studies showing “no benefit beyond placebo” with counter ‘personal experience’. The person thinks, ‘maybe they did the study wrong, or maybe I’m just an outlier, but it works for me. Of course, I don’t think it cures infectious disease or anything, but for what _I_ use it for, it really helps.’

In short, i doubt the OP bothers Tranformational Acupuncture or Urban Tao enough to generate more than a shrug…

But I’m glad Orac discussed Mioline’s piece because:

1) It seems like a good example of how patients actually see acu, (as opposed to how the needlers promote it), and that’s good to know if you want to persuade them toward sbm.

2) It’s in the Washingtonian, a ‘city culture’ magazine that caters to the city’s yuppie elites:

noted for its detailed coverage of area professionals, businesses, and places… top physicians, top places to dine, and top neighborhoods… listings of the latest fine entertainment, fine arts, and museum exhibits. Classified listings of prestigious real estate, and illustrated coverage of society social events… Perhaps its most significant undertaking is its ranking of the Washington area’s 80,000 lawyers.

I.e., Mioline’s article is in a publication devoted to offering the people who run things in the nation’s capital ‘lifestyle’ stories they want to read. The piece has a helpful provider map that shows acupuncture clinics are conveniently located to where power-brokers work and live. This isn’t a Berkeley with a loose ex-hippie vibe, or the upper SF peninsula with lots of Asian immigrants. It’s stuffy, middlebrow, striving, white-DC — as ‘mainstream’ as ‘mainstream’ gets.

We might then consider the larger significance of the appearance of this piece, and the particular approach it takes to acupuffery: vague, psuedo-pop-sciency, no overt mysticism, claims likely not implausible to the 80,000 best lawyers in what amounts to Lawyer City…

Denice:
Acupuncture isn’t like Oakland, because there is a there there. When Gertrude Stein said “there is no there(a) there(b)” she meant that the Oakland of that time (b) was a distinctly different place than the town she had known (a), growing up there.

There was a different there there then, that wasn’t her there, but both theres aren’t there now, and there’s another there there. So there.

It’s funny- When I was first trying to understand woo, I decided to interview an acupuncturist, so I walked into that very place Transformational Acupuncture in Dupont Circle and talked to Nadia, who was the receptionist and girlfriend of the proprietor Jeremy Riesenfeld.

Though Nadia was a very nice person and graciously answered my questions, she seemed to be quite the True Believer. I did ask whether Mr. Riesenfeld used gloves when he stuck needles into people, especially since DC has a high HIV rate. She responded that no, they don’t wear gloves but they wash hands often.

They had “community acupuncture” which is basically doing acupuncture on multiple people at once. Also featured was auricular acupuncture which pretends that the ear looks like a fetus, so sticking needles in the parts of the “fetus” corresponding to ailing body parts can fix those parts- It’s like voodoo with ears. They also sold assortments of herbs with labels in Chinese. Nadia told me these herbs had helped her allergies.

I’ve long wanted to ask my acu acquaintance about what the ancient Chinese practitioners of acupuncture did about infection control. Since making the needles would have been quite difficult, they presumably didn’t use disposables. And it’s highly doubtful they sterilized them between patients since I’m guessing they didn’t know much about bloodborne pathogens. So would it be fair to assume there’s a good chance they made many people a lot sicker rather than better? Spoiler alert: I’m not going to bother asking him.

This isn’t a Berkeley with a loose ex-hippie vibe, or the upper SF peninsula with lots of Asian immigrants. It’s stuffy, middlebrow, striving, white-DC — as ‘mainstream’ as ‘mainstream’ gets.

Washington does have a Chinatown: it’s four stops from Dupont Circle on the Red Line toward Glenmont. And the metro area does have a respectable proportion of Asian immigrants, albeit in smaller numbers than West Coast cities. But yes, it’s significant that this acupuncture practice is in the affluent Dupont Circle area rather than Chinatown. It’s as if actual Chinese people aren’t that much more likely to go for acupuncture than affluent whites.

Instead of the usual disclaimer (“The persons and events in this book are fictitious….” etc ), Kurt Vonnegut”s books have “Nothing in this book is true.” The Washingtonian article should have been headed by “Nothing in this article is true.” Why can’t I get a job like hers?

“There was a different there there then, that wasn’t her there, but both theres aren’t there now, and there’s another there there. So there.There was a different there there then, that wasn’t her there, but both theres aren’t there now, and there’s another there there. So there.”

So sorry to read that Orac’s mind was diverted by material in what is essentially a neighborhood throwaway. The line between editorial and advertising in that rag is razor-thin. Bird-cage liner stuff. And Chinatown is not so much a residential area anymore, I think. Owners of businesses there live out in the burbs, which is where I think you might find the old practitioners of traditional Chinese flim-flams. There used to be several purveyors of medical aids on the level of ground rhino horn in Chinatown when I lived near there. All the really scary Chinese woo has been driven underground, but it’s still there. Next year’s fad for the Dupont Circle and Adams-Morgan yuppie set will probably be cupping or some other detoxing nonsense.

Oddly enough, ancient acupuncture might have actually worked as a bit of a pain reducer, though modern practices have eliminated what would have helped. In the book “Thirty years in Moukden”, acupuncture in the late 1800’s is described as often involving heating metal until it is glowing red, then inserting the metal into the body, sometimes leaving it there for several days. That would fit in with the CPM (Contitioned pain modulation) model that a secondary source of pain will reduce the sense of pain from the primary condition.

Not a study to raise a skeptic’s pulse. What would do the trick would be a Cochrane Systematic Review or equivalent standard, showing clear and unambiguous evidence that acupuncture is superior to placebo.

Meanwhile, the urban myth continues to propagate its merry way. “Demystifying an Ancient Practice” is what we do here Elissa.